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John A. McGreal Jr., O.D. St. Louis, MO

My Top 10 Favorite Oral Drugs. John A. McGreal Jr., O.D. St. Louis, MO. Fexofenadine. Antihistamines Oral drug of choice / non-sedating 60mg, 180mg, available with decongestant Dosage: bid, qd Re-engineered Seldane / free of adverse cardiac effects of Seldane and Hismanal

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John A. McGreal Jr., O.D. St. Louis, MO

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  1. My Top 10 Favorite Oral Drugs John A. McGreal Jr., O.D. St. Louis, MO JAM

  2. Fexofenadine • Antihistamines • Oral drug of choice / non-sedating • 60mg, 180mg, available with decongestant • Dosage: bid, qd • Re-engineered Seldane / free of adverse cardiac effects of Seldane and Hismanal • Available as • Allegra 60mg bid • Allegra 180 qd • Allegra-D 12hr (60/120) for nasal congestion • Allegra-D 24hr (180/240) for nasal congestion JAM

  3. Doxycycline • Antibiotic – old and not very good for staph or strep • Long acting • 20, 50, 75, 100mg capsules • Excellent for meibomian gland dysfunction, blepharitis, ocular acne rosacea • Useful in minimizing structural damage from collagenase in cases of chemical burns, severe infectious ulcers, RCE • Dosages: 20, 50,75, 100mg PO bid • Rosacea: 100mg bid X 1 mos, then 100mg qd X 2 mos • Available as Doxycycline, Vibramycin, Alodox, NutriDox JAM

  4. New Ideas in Eyelid Care • Baby shampoo based scrubs dry out the eyelid skin & remove antibacterial skin oils • Scrubbing eyelid skin increases bacterial penetration and colonization • No shampoo based products have antibacterial effect • Anterior or posterior blepharaits patienyts have bacterial overgrowth on thei eyelids • Anterior – greasy skin flakes on lashes and inflammation on the anterior lid margin • Posterior – overgrowth results in sandy gritty irritation in morning JAM

  5. New Ideas in Eyelid Care • Production of bacterial lipases and esterases hydrolyze the wax and sterol esters in the meibum, creating free fatty acids that irritate the eye and may promote inflammation and resultant changes in tear film stability • Dry eye patients also have bacterial overgrowth on their eyelids • This bacteria inhibits conjunctival goblet cells proliferation in tissue culture, relative to normal controls • Mucus from these cell lubricates the ocular surface • Dry eye patients already have decreased goblet cell density secondary to increased tear film osmolarity • Punctal plugs are covered in a biofilm colonized by a diversity of organisms JAM

  6. Blepharitis Therapy – Topical/Oral • NutriDox Convenience Kit • Doxycycline 75mg tablets • Works synergistically with SteriLid to reduce bacterial colonization • Works synergistically with Theratears Nutrition to suppress inflammation • 30 tablets of antibiotic • TheraTears Nutrition omega-3 softgels (#90) • Thins meibomian secretions and reduces inflammation • iHeat Warm Compress System • iHeat Mask • iHeat Warming Units (#10) • Activated by pressing on them, maintains heat for 5 mins • Indications: Moderate-severe posterior blepharitis JAM

  7. Blepharitis Therapy – Topical/Oral • ALODOX Convenience Kit • Doxycycline 20mg (low dose) tablets • Below antimicrobial level, safer for prolonged use • Sustains collagenolytic activity, reducing inflammation • Ocusoft Lid Scrub Plus (Cynacon/Ocusoft) • 1 box of pre-moistened pads • 60 tablets of antibiotic • 1 bottle of 50ml Ocusoft Lid Scrub Original Formula • Covered by most insurances as tier 3 co-pay • $25.00 rebate • Assistance program through www.rxhope.com JAM

  8. Cephalexin • Action – cephalosporin • Gram positives, skin & skin structures • Dosage: • 1-4g/D; • 250mg qid, • 500mg bid, tid, qid, • 750mg bid • Contraindication: PCN allergy • Side effects - min • Available as Keflex, Keftab, Keflet JAM

  9. Erythromycin • Macrolide for skin & skin structures • Side effects – nausea, vomiting, diarrhea • Dosage: 200, 250 (generic), 333 (Filmtabs or PCE), 400, 500mg (E-mycin) • Available as 50 varieties with GI upset; 3 with enteric coated formulations to minimize side effects • Erythromycin ethylsuccinate (EES 400mg qid) • Erythromycin particles (PCE Dispertab 333mg tid, 500mg bid) • Erythromycin delayed (ERYC 250mg qid) • Available as Ilotycin ophthalmic ointment JAM

  10. Azithromycin • Macrolide • Drug of choice in children and adults, particularly in PCN allergy • Long half life • Excellent bioavailability • Side effects similar to erythromycin but less • Dosage: Z-PAK 500mg / day 1, then 250mg / days 2-5 • Dosage: TRI PAK 500mg qd for three days • Dosage: ZMAX single 2.0g dose • Pediatric dose: 12mg/kg/D • Available as • Zithromax Z-Pak, Zithromax TRI PAK, ZMAX, AzaSite topical • Simple, convenient, effective JAM

  11. Acyclovir • Antiviral for simplex, zoster & chickenpox • Dose form – 200, 400, 800mg tablets, 200mg/5ml • Primary Herpes Simplex: 400mg- 5x/D x10D • Chronic Suppressive: 400mg bid daily for prophylaxis x 1yr • Varicella: elixir 20mg/kg per dose- 4x/D x 5D (initiate within 24h) • Children over 40kg receive adult dose • Herpes Zoster: 800mg- 5x/D x 10D (initiate within 72h, 48h best) • Expensive • Side effects: nausea, diarrhea • Only caution is with renal impairment • Available as Zovirax JAM

  12. Methylprednisolone • Oral corticosteroid • Indications: Allergic reactions, dermatologic reactions, stubborn iritis witch is slow to respond to intensive topical steroids, Bell’s palsey • Side effects – avoid in diabetics, otherwise safe for short term applications • Dosage: 6 day, 21 tablet, self-tapered dose form • Available as Medrol 4mg DOSPAK (generic) JAM

  13. Types of Analgesics • Narcotic analgesics • Opiates or opioids • Controlled substances • Actions • Bind to opiod receptors in the brain, brainstem, and spinal cord • Mimic the effect of endogenous opioid peptides (endorphins) • Affect both the sensation of noxious stimulation and the emotional component of subjective distress • Clinical stratification of pain • Mild to moderate pain • Moderate to severe pain • Most severe JAM

  14. Narcotic Analgesics • Side effects • CNS • Sedation, lightheadedness, dizziness, drowsiness, euphoria • GI • Nausea, vomiting, constipation • Respiratory depression • Contraindications • Hypersensitivity to narcotics • Respiratory disease • Kidney or liver diseases JAM

  15. Oral Narcotic Analgesic - Guidelines • Prescribing hints • Never exceed maximum recommended amounts • ASA - 8g/D • APAP - 4g/D • Ibuprofen - 1200mg/D OTC & 2400mg/D Rx • Codeine - 360mg/D • All have abuse potential • Precautions • No EtOH • Do not operate machinery JAM

  16. Oral Narcotic Analgesic - Guidelines • Establish the proper diagnosis • Treat the underlying disease (root-cause) • Treat pain with the simplest and safest means to achieve comfort and adjust the treatment according to response or patient threshold • Treat pain at presentation – do not wait! • Treat pain continuously over 24h schedule • Nonprescription drugs are usually a low-cost effective first choice JAM

  17. Oral Narcotic Analgesic - Guidelines • Mild to moderate pain is often successfully treated with NSAIDs and acetaminophen • Moderate to severe pain is best treated with opiod analgesics • Adjunctive treatments are very valuable in pain management • “RICE” – rest, ice, compression, elevation • Mydriatic / cycloplegia useful with ciliary ocular pain • Bandage contact lenses or pressure patches for epithelial defects JAM

  18. Codeine • APAP / Codeine 15, 30, 60mg (Tylenol #2, 3, 4) • ASA / Codeine 15, 30, 60mg (Empirin #2, 3, 4) • Schedule III • Side effects • Lightheadedness, dizziness, sedation, nausea, vomiting, euphoria, constipation • Pediatric dose – 0.5mg/kg/day • 3-6 yrs 5ml tid-qid (1 teaspoon) • 7-12 yrs 10ml tid-qid (2 teaspoons) JAM

  19. Hydrocodone Actions – narcotic analgesic and anti-tussive • Combination with acetaminophen mostly, some ibuprofen • Uses • Moderate –moderately severe pain • Cautious use in elderly debilitated patients with renal or hepatic problems • Dose q4-6h • Available as Vicodin 5mg/500mg

  20. Hydrocodone • Vicodin 5/500mg APAP • Vicodin ES 7.5/750mg APAP • Vicodin HP 10/660mg APAP • Vicoprofen 7.5/200mg Ibuprofen • Hycodan 7.5/1.5mg homatropine methylbromide • Subtherapeutic dose of HA for antitussive affect • Lorcet 10/650mg APAP • Lorcet HD 5/500mg APAP • Lorcet Plus 7.5/650mg APAP • Zodone 5/400, 7.5/400, 10/400mg APAP

  21. Acetazolamide • Oral CAI with attendant side effects • 250mg, 500mg sequels (time released) • Dosage – qid for 250mg, 500 bid for sequels • Sequels best for reduced side effects in long term chronic use but never use sequels for acute glaucoma • Side effects – paresthesias of fingers and lips, acid-base shifts, urinary calculi, impotence, thrombocytopenia, hypokalemia • OJ or banana or supplemental potassium to limit side effects, periodic CBC • Contraindicated in sulfa allergy • Excellent as quick IOP lowering agent in acute glaucoma • Available as Diamox JAM

  22. EyePromise Restor • Oral supplement for macular degeneration and at risk groups • Improves MPOD over 6-12 months, reduces glare, improves contrast sensitivity • Beneficial for dry eye, cataracts and wellness along with multivitamins • Ingredients • No beta-carotene or vitamin A • Vitamin C • Vitamin E • Zinc • Lutein • Zeaxanthin • Omega-3s • Alpha-linoleic acid JAM

  23. Is MPOD Related to AMD? • Three donor eye studies published, all show 30-50% less pigment in AMD eyes vs controls • Moran Eye Center (Bernstein) Raman method • Manchester UK group HFP method found AMD patient eyes had 50% lower MPOD • Germans found 50% lower MPOD in dry AMD patient eyes • Dutch group did cross sectional prospective study using reflectance and found no difference on MPOD in early AMD

  24. Macular Pigment Studies • Optom 2008; 79:266-272 Lueng • Optometrist play key role in assessment & monitoring risk of AMD • LAST Study (Lutein Antioxidant Supplement Trial) • 12 month study • 90 male VA patients • Lutein 10mg vs Lutein 10mg & MV vs Placebo • Lutein only or combination increases MPOD by >50%, Glare recovery, contrast sensitivity and visual acuity JAM

  25. Macular Pigment Studies • OptomVisScience 2008; Stringham & Hammond • Six months of L/Zx increased MPOD • Decreased glare disability 58% • Decreased photostress recovery time 14% • Ophthal 2008 Feb 115(2):334-341 Blue Mountain Eye • Higher intake of L/Zx reduced risk of AMD • Confirmed protective benefit of zinc • Higher beta carotene increased risk AMD JAM

  26. Macular Pigment Studies in Cataracts • ArchOphthal 2008; Mueller et al • CAREDS/WHI • N=1802 women with highest levels of L/Zx had 32% lower incidence of NSC • Ophthal 2008 115(8) Sperduto et al • NEI Trial of Centrum Silver • N=1020 18% less lens events • AmJClinNut 2008; Tan et al Blue Mountain Group • N=2464 Vit C and dietary antioxidants decreased NSC 50% JAM

  27. Macular Pigment Studies in Diabetes • IOVS 2008; Gierhardt et al • Proved Zx mechanism of protection in early DR • Anti-inflammatory & VEGF regulation • CAREDS 2007 Diabetic women have 30% lower MPOD • Graetes 2008 Spanish Group • Fed diabetic rats lutein and found it to be as effective as insulin at preventing cataract JAM

  28. Nutritionals • EyePromise (ZeaVision) • Zeaxanthin 8mg • in the same 2:1 ratio as found in healthy macula • Lutein 4mg • Beta carotene – none • Vitamin C – 120mg • Vitamin E – 60 IU • Zinc – 15mg • Copper – none • Fish oil (omega-3) – 250mg • Alpha Lipoic acid – 10mg JAM

  29. Cardiovascular Prevention Bonus Round

  30. Oral NSAID - Aspirin Aspirin (ASA) – salicylic acid derivative • Anti-platelet activity at low dosages (D/C prior to surgery) • Primary action is to reduce hypothalamic prostaglandin levels at average doses (325-1000mg q4-6h) • Significant anti-inflammatory effects at higher doses (600-5200mg daily) • Preventative effects at low doses (81mg) • Side effects • Hypersensitivity reactions • GI upset, bleeding • Salicylism at high doses (dizziness, tinnitus, headache) • Associated with Reyes' Syndrome in children with fever and viral illness • Blurred vision and color changes • Caution in asthmatics • Lethal dose is 10-30g (adults) and 4g (children)

  31. Oral NSAIDs Aspirin (ASA) – salicylic acid derivative • Aspirin (generic) 325mg, 81mg (low dose) as daily prohylactic for at risk groups • Bayer 325mg • Empirin 325mg • Ecotrin 325mg • Enteric coated • Ascriptin 325mg • Coated, buffered • Bufferin 325mg • Coated, buffered

  32. Oral NSAIDs Aspirin (ASA) – salicylic acid derivative • Aspirin (generic) 325mg, 81mg (low dose) as daily prophylactic for at risk groups • Bayer Children Low Dose 81mg (chewable cherry & orange) • St. Joseph 81mg chewable & enteric coated • Aggrenox – ASA 25mg & dipyridamole 200mg extended release form • Indicated to reduce risk of stroke in patients with TIAs or completed stroke due to thrombosis • Butalbital/ASA/Caffeine • Butalbital/ASA/Caffeine/Codeine

  33. Oral NSAIDs Aspirin (ASA) – non-narcotic combinations • Anacin caplets Aspirin 400 / Caffeine 32 • Anacin (max) Aspirin 500 / Caffeine 32 • BC Powder Aspirin 650 / Caffeine 32 / Salicylamide 195

  34. Thrombolytics for MI • Acute Coronary Syndromes • Reteplace (Retavase) • Eptifibatide (Integrilin) • Tirofiban (Aggrastat) • ASA (Bayer) 325mg chewed STAT • Drug-eluting or bare metal stents • Prevention • ASA 81mg (only 1/3rd of 62 million at risk in US use ASA) • Reduces 1st MI risk by 32%, 2nd MI risk by 20% JAM

  35. Thank you McGreal Educational Institute An educational affiliate of Missouri Eye Associates JAM

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